Health workers' job satisfaction plays a key role in the quality of health service delivery. Given the specific responsibilities of CHWs in the context of Rwanda where they fill an important gap in health service delivery, understanding the predictors of their job satisfaction is key in proffering policy solutions for improving the quality of their work. Overall, CHWs satisfaction was found to be significantly associated with mainly structural level factors including level of motivation, role performance, individual supportive supervision, formal training, access to required materials, peer support and in-kind benefits from the community, among others. This finding emphasizes the important role of overarching structural factors in guaranteeing CHWs job satisfaction in the context of Rwanda. However, overall, the results of this study indicate that the proportion of CHWs who are highly satisfied with their work is more than those who may be dissatisfied. These findings were found to be largely consistent with the studies of Ding et al.24 and Mpemberi et al.25 also emphasize the role of structural factors in guaranteeing the job satisfaction of health workers.
Given the evidence of a link between job satisfaction and performance, researchers often use workers' performance as a proxy to measure their job satisfaction as workers who are high performers also tend to report higher job satisfaction26,27. Consistent with this observation and a recent study by Khatri, Mishra, and Khanal28, the middle and high performing CHWs workers in this study had a higher likelihood of reporting job satisfaction compared to CHWs who reported low performance. Earlier, studies29,30 have highlighted a bidirectional relationship between job satisfaction and performance where 11.8% of health workers' performance was explained by their job satisfaction. In this regard, in evaluating CHWs job satisfaction in Rwanda, stakeholders can achieve this through performance appraisals, and where CHWs performance is seen to be below a set target, appropriate measures can be put in place to address any outstanding issues that may be adversely affecting their job satisfaction.
Furthermore, the finding that motivation was a significant predictor of CHWs satisfaction may not be too surprising. Specifically, community health workers with middle to high motivation were more likely to belong to a high category of job satisfaction compared to those with poor motivation. This finding is consistent with the current literature`s suggests that motivation, whether intrinsic or extrinsic, plays a key role in health workers' job satisfaction25,34−37. Besides, Lambrou et al.31 also found that intrinsic factors measured by internal thought processes and perceptions about motivation, and extrinsic factors measured by monetary rewards and recognition for work done, greatly influenced health workers' job satisfaction. However, CHWs` motivation and its link to their job satisfaction could also be due to the overwhelming community recognition of their work16,33. Similar links were revealed by a study conducted by Liverpool School of Tropical Medicine Centre for Maternal and Newborn Health, in collaboration with UNICEF and Rwanda Biomedical Center (RBC), where most CHWs exhibit intrinsic motivation as recruitment into the program was mostly voluntary with no financial compensation. In this regard, only individuals with a desire to help address persistent maternal and child health care challenges in the community opted to be trained and commissioned as officers despite insufficient remunerations32. It is therefore imperative for the Rwandan government to effectively harness this high level of motivation to ensure the delivery of high-quality health services in rural communities by CHWs.
The findings further revealed that CHWs with high knowledge about their primary mandate, specifically, maternal, newborn and child health care were less likely to report job satisfaction. Although this finding may seem counter-intuitive, it is possible that CHWs with high knowledge of their mandates and conscious of the important function they serve in the healthcare delivery chain are dissatisfied with some existing inefficiencies impeding their ability to effectively discharge or execute their mandates in reducing maternal and child mortality. Consistent with this observation, Mathauer and Imhoff34 have revealed that, where health workers are unable to perform their duties because of bureaucracies and other delays in accessing the necessary tools to perform their duties, they become frustrated and often report job dissatisfaction.
Both quantitative and qualitative literature have discussed the importance of supportive supervision on job satisfaction among health care workers in several contexts38–40. According to previous studies, the supervision of community health workers in developing countries is critical to ensure that they perform well, deliver quality services and be motivated41–43. Consistent with these scholarships, findings from this study revealed that lack of supervisory support negatively affects CHWs` work satisfaction. Thus, CHWs with at least one supportive supervision a month were more likely to be in a high category of work satisfaction compared to the CHWs who have never been supervised before the survey. It is suggested that through supportive supervision, supervisors get the opportunity to consult with CHWs and give value to CHWs` decisions and feelings as they perceive their work is valued and appreciated and through this, enhance their greater work satisfaction44. In addition to supervision from superiors, Hill et al.38 have also emphasized the importance of community and peer supervision for CHW which was also found to be associated with improved work performance. Earlier studies in Rwanda identified sufficient supervision as a major barrier affecting effective service delivery by CHWS16. Thus, this finding suggests that stakeholders of the CHWs program might need to pay particular attention to this critical to improving supportive supervision.
In addition to supportive supervision, training of CHWs before the commencement of their duties and other in-service training is seen as particularly useful in enhancing their knowledge and skills for service provision. Training as an indispensable tool in the work of community health workers is useful in the transfer of useful skills and information for the effective delivery of health services to hard-to-reach populations44,45. CHWs, therefore, consider training as an essential component in achieving their mandate as health workers. Among others, CHWs explained that more frequent training improved their efficiency, confidence, and knowledge base as most of them are not originally trained as a health professional. They feel empowered and respected within their respective communities when they receive training from superiors who are active health service professionals with many years of work experience16. To this regard, it may not be surprising that in this study CHWs who received formal training in CBMNCH were more likely to be in a high category of job satisfaction compared to those who have never received formal training in CBMNCH. Therefore, CWHs who received limited or no training were less likely to be satisfied with their job given its adverse influence on the effective delivery of their mandates as community volunteers. These findings further suggest that stakeholders in the CHWs program should focus on making the training of CHWs more frequent to give them opportunities to improve their knowledge and skills. This will likely lead to better performance of their assigned tasks which could also improve their feeling of accomplishment (satisfaction) from their work.
Furthermore, in the health delivery literature, peer support is a crucial factor in the retention of health workers as they share knowledge and discuss how to surmount challenges in the performance of their daily duties. In this study, peer support, as one of the facets of job satisfaction, was also examined and it was found to be a predictor of job satisfaction for CWHs. CHWs who had good peer support were more likely to be in the high category of job satisfaction compared to their counterparts. These results were consistent with other studies such as Jayasuriya et al.46, who found relationships with colleagues and other forms of peer support to be a strong predictor of job satisfaction. Similarly, other scores of scholars47,48 from a qualitative enquiry approach have shown inter-personal relationships as an important ingredient in health workers' motivation. This finding is very useful for policy consideration among CHWs stakeholders as they can target strengthening peer support activities as this is currently not implemented in the study context.
Access to working materials and other essentials is necessary for meeting targets and effective discharge of responsibilities for health workers particularly in the context of developing countries. Therefore, although financial rewards are important for motivating, retaining and ensuring health worker satisfaction, the presence of adequate resources in the form of supplies and essentials is very useful in improving the morale and work satisfaction of health workers significantly49. In this context, it may not be too surprising for this study revealed that CHWs who had limited access to assessment tools which is important in the discharge of their duties were less likely to report being satisfied with their jobs compared to those that had regular access to these materials. Other studies50,51 have reported the same findings. These suggest that it is necessary to sufficiently equip CHWs to perform their work and that in turn could improve their work satisfaction.
While financial rewards and motivation are linked to health worker job satisfaction and retention in many contexts33,42,43, in Rwanda, the community health worker program is mainly voluntary and based on little or no remuneration. However, CHWs are encouraged to form cooperatives where they initiate income generation activities and profits from these initiates may be used by CHWs as financial compensation for their work. Thus, cooperatives serve as the main source of financial remuneration for CHWs. The findings reveal that CHWs who perceived their cooperatives to be profitable, implying they may be gaining some financial rewards from their cooperatives were more likely to report job satisfaction compared to those who did not belong to a profitable cooperative. In this regard, it can be argued that although the CHW program was established voluntarily, financial remuneration may still be playing a key role in CHWs job satisfaction as reported by earlier studies25,43,52. Furthermore, CHWs who received payment in kind for their services were more likely to have job satisfaction compared to those that were not receiving any payments from community members. Given the voluntary base of services rendered by CHWs to their community, payments in kind make CHWs feel appreciated for their work, explaining why they are more likely to have better job satisfaction16,34. Based on these findings, it may be critical for stakeholders of the CHW program in Rwanda to rethink how they can provide a suitable financial incentive to CHWs to engender strong feelings of governmental support and in turn, better job satisfaction.
In general, work satisfaction revolves around feelings and attitudes that an individual has with regards to their work that motivates them to fulfil an anticipated target or achievement52. Given the multiplicity of factors that are associated with health workers’ job satisfaction, this study argues that in the context of Rwanda, CHWs can be satisfied with some aspects of their job and the same time remain dissatisfied with other aspects that fail to meet their expectations. Therefore, this study suggests a holistic approach in considering all the possible factors associated with work satisfaction of CHWs.
Whilst this study provides greater insights into the CHWs’ job satisfaction in the provision of CBMNCH services for timely access to MNCH in rural communities Rwanda, there are some limitations. First, the study was conducted in high need districts, making it difficult to extrapolate the finding to the rest of the country. Second, given that respondents were asked to recall most of the responses, some of the responses may be subject to recall bias which may influence the reliability of the collected data. However, the likelihood of recall bias was reduced by reducing the recall period to a maximum of 12 months. Lastly, given the cross-sectional nature of this data, findings are only restricted to statistical associations and therefore, causal-effect could not be inferred.